syphilis and that the latter is characterized by more frequent depressive symptoms and periods. In syphilis the mental degradation is more rapid, more explosive, than in paresis and the automatic faculties are less preserved. The victim of paresis will be capable of intelligent performance of duties to which he has been accustomed at a time when his disease has progressed to such a point as to render him an imbecile on general topics in which he has had only a cursory interest during the period of his unimpaired mentality. In spite of many and varied types of paresis, the disease still possesses a unity which gives to it a marked individuality, whereas the mental manifestations of syphilitic insanity, conforming to the physical distributions of the lesions are characterized by the widest variations. Paresis, again, is characterized in many cases by a sort of assumed bravado not unlike intoxication, the patient at the same time being more or less conscious that something is wrong with his mind and at times tormented with a distinct fear of losing his mind. Attention is called to the following illustrative cases: Case I. In October, 1898, W. C., aet. 30, was sent to me from one of the larger towns of Kansas. Dr. J. R. Snell had seen the patient and pronounced the case one of brain syphilis, a diagnosis which I promptly confirmed. There was ptosis of right eye, unsteady gait, marked delusions of wealth, mentalirritability. On learning my diagnosis, the family physician told me that he knew the patient had never had syphilis. In this, of course, he was mistaken. The mental symptoms rapidly vanished under specific treatment and patient was discharged and advised to continue his medicine for two years. After a few months another physician advised him to omit his medicine. He did so and at the end of a month had a series of terrific convulsions. This patient is still under observation and his brain is permanently impaired; mind nearly normal. Case 2. J. M., aged 35, had every characteristic mental symptom of paresis on coming to me from Colorado, in May, 1901. Somatic signs absent; syphilitic history nearly negative. Dr. Kemble of Denver wrote me that he had not had syphilis. After six weeks or two months of non-specific treatment, ptosis and diplopia suddenly appeared. Vigorous antisyphilitic treatment was at once instituted and in two weeks the ocular symptoms disappeared. The patient is still under treatment and is nearly well, but there will always be a slight blur upon the brain. Case 3. F. R., aged 40, was admitted to the sanitarium in 1901, suffering from neurasthenia and optic neuritis. No history could be more strongly negative as regards syphilis. Patient could not distinguish persons except as dark moving objects. In six weeks, under administration of full doses of iodides, could readily count fingers. Diagnosis still in doubt. THE TREATMENT OF DROPSY OF CARDIAC DISEASE. In the earlier stages of valvular diseases of the heart, in which the interference with the circulation of blood through the organ has been fully compensated by hypertrophy of the heart muscle, no indication presents itself for the use of diuretics. It is in the later stages when compensation fails.and when the hypertrophy gives place to a condition of dilatation that these remedies are frequently required. Owing to the weakening of their walls the ventricles are no longer able to propel the blood in sufficient quantity and with sufficient force through the vascular system, and this is further increased by the lowered tension in the arteries. Under these circumstances the blood tends to stagnate in the various organs and a condition of venous stasis results, with the exudation of serum into the tissues and the cavities of the body. The management of these cases of cardiac dropsy is rendered still more difficult by the frequent existence of renal disease as the result of the cardiac lesion. While it is impossible to formulate any special system of treatment, since this must depend to a great extent upon the conditions present in individual cases, it may be permitted me to briefly discuss this subject in the light of my own experience. For the relief of dropsy in cardiac disease a number of methods are at our disposal. It may be sufficient to administer remedies which will increase the force of the heart and raise the arterial pressure, such as digitalis, convalearia, strophanthus, etc., these drugs being known as indirect diuretics. In connection with these it is a common practice to administer alkalies, especially acetate of potassium, which tends to stimulate osmosis in the glomeruli and also promotes the elimination of solids in the urine. Then there is a group of diuretics which act directly upon the renal epithelium, comprising such remedies as squills, juniper and cubebs, but their use is rarely admissible owing to their irritating effect upon the kid neys, which may give rise to severe congestion and light up an acute process in these organs. Hence before resorting to them the condition of the kidneys should be carefully determined by an examination of the urine. If evidences of organic changes in the renal secreting structures are found we should abstain. from the employment of this class of diuretics. For this reason they are rarely of service in cardiac dropsies owing to the frequent presence of renal complications. Another means of removing dropsical effusions in diseases of the heart is by the use of cathartics. The compound jalap powder has been extensively employed for this purpose, while many prefer the administration of calomel. It must be remembered, however, that in patients suffering from cardiac disease the use of drastic cathartics is fraught with danger on account of their debilitating effect, and therefore they must be administered very cautiously, if at all. The same remarks apply to the use of diaphoretics, and even in a stronger degree. They all have a depressing action. upon the heart and seriously interfere with its functions. Quite a number of deaths from heart failure in the Turkish bath have been reported. We finally come to a group of diuretics which are of special value in the dropsy of cardiac disease, because of their comparative freedom from toxic effects. These are derivatives of caffeine and theobromine, especially the latter. Caffeine is a rather unreliable diuretic, while theobromine is considered much more efficient. Theobromine itself, however, cannot be utilized, particularly owing to its difficult absorption, and for this reason various double salts have been suggested, the latest of which is known as agurin, being chemically aceto-theobromine sodium. The advantages of this salt are, that, unlike the salicylate of theobromine, it is free from any irritating effect upon the gastrointestinal tract and kidneys, while the acetate of sodium, which is one of its ingredients, participates in its diuretic action. Agurin appears as a colorless powder, having a salty somewhat bitterish taste, soluble in water. It is best administered in wafers or capsules or in freshly prepared solutions. In giving it in solution the addition of syrups should be avoided, so as to obviate any precipitation of theobromine. The dose varies from 5 to 10 grains, three or four times daily. This preparation was discovered by Dr. Impens, who, in experimenting with various theobromine salts on animals, gave it the preference over any of the others. It was next tried in the clinic of Destree of Brussels, and found to be of value in cardiac dropsies, in which it increased both the excretion of water and solids in the urine, especially the chlorides and phosphates. For this reason he regarded it as contraindicated in cases of phosphaturia. In v. Litten's clinic in Berlin, experiments with agurin also proved very satisfactory, and under its administration the amount of urine was rapidly increased, sometimes in a remarkable degree. Favorable reports have also been made by Professor Buchwald of Breslau, Dr. Holle from the clinic of v. Ziemssen, in Munich, De Buck of Brussels, Dr. Reye from the clinic of Professor Lenhartz, in Hamburg, and by Dr. A. Hess, from the clinic of Professor Fuerbringer. From these observations it appears that agurin is quite a useful diuretic in cardiac dropsies, having the advantages of being well tolerated and of not affecting the heart. If necessary, it may be given in connection with digitalis and other cardiac tonics. As the remedy has been but recently introduced it may prove of interest to place on record two cases of which I have complete notes, and which will serve to illustrate its action. Case I. Mrs. R. B., 40 years old, a mother of five children, has had recurrent acute articular rheumatism since the age of sixteen. Her heart, though showing evidence of mitral lesion and hypertrophy of the left ventricle for several years, gave no other symptoms than slight dyspnea after exertion until a month. ago. At this time edema of the lower extremities appeared, and in spite of the cardiac tonics and diuretics it spread upward in the course of two weeks until fluid manifested itself in the peritoneal cavity. Examination of the urine revealed the presence of a small amount of albumin, but no casts. On the recommendation of one of my medical friends I administered as a last resort agurin in 5-grain doses, three times a day in wafers. The urine increased in quantity wonderfully. After the first day's use of agurin it increased from 500 c. cm. to 1,500 c. cm.; on the second day to 2,000; on the third to 2,600, and on the sixth to 3.0000 c. cm., or to six times the quantity she had voided before its administration. The effusion became daily less and less, and now edemà exists only in the ankles and this also disappears after a night's rest. The patient is still under treatment. I have no doubt but that perfect circulation will be established in a short time. The drug did not irritate the stomach, nor did it show any cumulative effect. Case II. I was summoned in haste to the bedside of Miss A. R., who was suffering with marked dyspnea. On examination I found the heart's action rapid and irregular, the apex beat diffused, the cardiac area enlarged, and a loud mitral regurgitant murmur present. Her lower extremities were edematous and I detected fluid in the abdominal cavity. She was markedly cyanosed and insisted on maintaining a sitting position. Her stomach was very irritable. I ordered 5-grain doses of agurin in peppermint water every four hours. The result was excellent. She voided large quantities of urine several times a day; her dyspnea disappeared in a few days and in two weeks all signs of dropsy had vanished. I continued the agurin in smaller doses and in addition gave potassium iodide, inasmuch as her cardiac lesion depended on acquired syphilis. In conclusion I would say that my results with agurin, which coincide with those obtained in v. Litten's clinic, as published in the Deutsche Aerzte-Zeitung, December 15, 1901, permit of the following deductions: 1. That agurin has the advantage of not irritating the stomach and kidneys. 2. That it is a more powerful and efficient diuretic than the other salts of theobromine. 3. That while indicated in many conditions of dropsy it is especially valuable in that due to valvular disease of the heart. ANESTHESIN A LOCAL ANESTHETIC. By PROF. CARL VON NOORDEN. (NH H, The ethyl-ester of P-amido-benzoic acid C, H, COOC, H ̧ was first prepared by Dr. E. Ritsert of Frankfort on the Main in 1890 and was recognized by him as a non-toxic local anesthetic. Although this substance aroused great interest among various pharmacologists as a member of a hitherto unknown group of anesthetics, and was especially welcomed by Filehne as a confirmation of his theory of the anesthetic action of the benzoyl group, clinical proof was lacking because of the difficult solubility of the substance in water, which thus afforded no prospect of fulfilling the long cherished desire of securing a non-toxic substitute for cocain. Some seven years later Meta-amido-p-oxybenzoic-methyl ester (orthoform) was prepared by Einhorn and despite its insolubility in water was introduced into therapy; whereupon it now became advisable to subject the forgotten amido-benzoicacidester to clinical examination, and all the more so because orthoform had been criticised for its irritating quality and the relative toxicity which produced from its phenol-characteristics. It was expected that these unpleasant collateral effects would be much less noticeable in the case of an amido-benzoicacidester, which was designated anaesthesin. Dr. Ritsert gave this preparation to me some two years ago; since which time I have used it uninterruptedly, and possess a very extensive experience with the agent. Anaesthesin is a white powder, without odor or taste. When placed upon the tongue a sense of numbness results. The drug is soluble with difficulty in cold water, somewhat more freely in warm water and very freely in alcohol, ether, chloroform, acetone, fats and oils. It may be mixed with fats of all kinds to form ointments without undergoing decomposition. At my request, Prof. Benz of Bonn instituted certain animal experiments in order to test the toxicity of anaesthesin. One of these experiments may be cited in this connection: |